Eli's Rehab Report

Watch out for phrases like 'one or more areas' when you're reporting therapy codes

Release carpal tunnel syndrome (CTS) reimbursement by taking two steps: Key in signs and symptoms until you have a definitive diagnosis, and avoid common mishaps when reporting various tests and therapy techniques.

Hold Back Coding CTS Until Confirmed
 
When a patient sees your provider and says she thinks she has CTS, you shouldn't code the visit as if this is the case.

Rule: When your provider sees a patient for suspected CTS, you'll need to report signs and systems such as numbness/tingling (782.0 Disturbance of skin sensation), decreased grip or muscle strength (728.87 , Muscle weakness), pain (such as, 719.43, Pain in joint, forearm), and other ICD-9 codes to justify testing. "Coding for the reason of the visit is always appropriate," says Maria Johnson, CPC, project coordinator at MedaPhase Inc. in San Antonio.

You shouldn't use 354.0 (Carpal tunnel syndrome) until your provider makes the definitive CTS diagnosis. Another condition may be the cause, such as cubital tunnel syndrome (354.2, Lesion of ulnar nerve).

Note: Commonly, patients have a "double crush" type of injury in which the CTS coexists with thoracic outlet syndrome (353.0) or cervical spine pathology, says Chris Sorrells, OTR, CHT, CEAS, an occupational therapist at Rehabnet Outpatient Center in Santa Monica, Calif. So when you see carpal tunnel syndrome on your provider's notes, don't automatically think this is the only diagnosis you'll use. 

Named Tests Don't Always Point to Extra Work

When a patient presents with hand and wrist pain and thinks she has CTS, your provider will perform specific tests to determine whether this is the case.

Warning: Don't think that payers should reimburse these tests separately. "I perform tests, such as Phalen's or Tinel's, on suspected carpal tunnel patients," Sorrells says. Tinel's sign is a tingling that patients may experience in their thumb, index, and middle finger when the provider taps on the median nerve in the wrist. In the Phalen's test, the patient rests the elbows on a table and lets the wrists dangle with the backs of the hands pressed together for one minute, which can prompt CTS symptoms.

"I include these tests under my standard evaluation charge. Without these tests, I cannot plan the patient's treatment," Sorrells says. "I do not code for them separately." Just because these tests have distinct names doesn't mean the service is separate and distinct from the physical examination component of an evaluation code.

Although tests like Phalen's or Tinel's are built in to the fee of an E/M visit, some providers may order other tests that can be reported separately. For instance, a physiatrist may take an x-ray (73100, Radiologic examination, wrist; two views) to examine the patient's bones and determine if any abnormalities may be contributing to carpal tunnel syndrome or another disorder.

Keep in mind: To make a definitive diagnosis of CTS, your provider may use electromyography (EMG, 95860-95872) or nerve conduction studies (95900-95904). When you're coding these studies, remember that nerve conduction studies are bilateral-exempt.

In other words, you should not report 95900 (Nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study) with modifier 50 (Bilateral procedure) to indicate that your provider tested both hands. Instead, you should code each entry on a separate line: 95900 with modifier LT (Left side) and 95900 with modifier RT (Right side), Johnson says.

Note: Some payers may contradict this rule, so make sure you have in writing what your payers prefer.

Grip Onto 3 Therapy Code Terms

Following a CTS diagnosis, a patient will begin conservative treatments that may include anti-inflammatory medications, splinting to immobilize the patient's wrist (29125, Application of short arm splint [forearm to hand]; static), and various therapy techniques.

Your best bet for getting your coding right at the outset is to pay attention to the following terms in the codes' descriptors: "one or more areas," "each 15 minutes," and "direct one-on-one" contact.

One or more areas: To relieve the patient's pain, your provider may use hot packs (97010, Application of a modality to one or more areas; hot or cold packs), paraffin baths (97018, ...paraffin bath), and whirlpools (97022, ...whirlpool). The term "one or more areas" means that you shouldn't use these codes more than once if your provider is supplying the service to both hands on the same date of service.

Note: Although you can receive reimbursement for a hot pack alone, most payers will deny a hot-pack charge when you're reporting any other therapy code on the same date of service.

Each 15 minutes: When you're reporting therapy codes such as 97140 (Manual therapy techniques [e.g., mobilization/manipulation, manual lymphatic drainage, manual traction], one or more regions, each 15 minutes) or 97504 (Orthotic[s] fitting and training, upper extremity[ies], lower extremity[ies], and/or trunk, each 15 minutes), you'll have to report your units according to the 8-minute rule. In other words, if your provider performs 97140 for 20 minutes, you should report only one unit. You should not report two.

Direct one-on-one contact: In addition to these modalities and therapies, Sorrells says, patients with CTS can benefit from activities-of-daily-living training (97535, Self-care/home management training [e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment] direct one-on-one contact by provider, each 15 minutes) - especially when the CTS affects the dominant side. The descriptor "direct contact" means the provider must be present in the room during the entire time. He trains the patient on a one-to-one basis. Make sure your provider documents this.

Note: Want to make sure you're reporting your therapy units correctly for CTS patients? Post the 8-minute rule. For a free PDF you can use, e-mail the editor at suzannel@eliresearch.com.